Appendix, C45 P293-301 Flashcards by Tiggee R

What vessel provides blood
supply to the appendix?
P293

Appendiceal artery—branch of the

ileocolic artery

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Name the mesentery of the
appendix.
P293

Mesoappendix (contains the appendiceal

artery)

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How can the appendix be
located if the cecum has
been identified?
P293

Follow the taenia coli down to the
appendix; The taeniae converge on the
appendix

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What is it?

P294

Inflammation of the appendix caused by
obstruction of the appendiceal lumen,
producing a closed loop with resultant
inflammation that can lead to necrosis
and perforation

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What are the causes?

P294

Lymphoid hyperplasia, fecalith
(a.k.a. appendicolith)
Rare—parasite, foreign body, tumor
(e.g., carcinoid)

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What is the lifetime
incidence of acute
appendicitis in the United
States?
P294

≈7%!

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What is the most common
cause of emergent abdominal
surgery in the United States?
P294

Acute appendicitis

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How does appendicitis
classically present?
P294

Classic chronologic order:
1. Periumbilical pain (intermittent and
    crampy)
2. Nausea/vomiting
3. Anorexia
4. Pain migrates to RLQ (constant and
    intense pain), usually in <24 hours

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Why does periumbilical pain
occur?
P294

Referred pain

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Why does RLQ pain occur?

P294

Peritoneal irritation

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What are the signs/symptoms?

P294

Signs of peritoneal irritation may be
present: guarding, muscle spasm,
rebound tenderness, obturator and psoas
signs, low-grade fever (high grade if
perforation occurs), RLQ hyperesthesia

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Define the following terms:
Obturator sign
P294

Pain upon internal rotation of the leg
with the hip and knee flexed; seen in
patients with pelvic appendicitis

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Define the following terms:
Psoas sign
P295

Pain elicited by extending the hip with
the knee in full extension or by flexing
the hip against resistance; seen classically
c retrocecal appendicitis

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Define the following terms:
Rovsing’s sign
P295

Palpation or rebound pressure of the
LLQ results in pain in the RLQ; seen in
appendicitis

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Define the following terms:
Valentino’s sign
P295

RLQ pain/peritonitis from succus
draining down to the RLQ from a
perforated gastric or duodenal ulcer

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Define the following terms:
McBurney’s point
P295 (picture)

Point one third from the anterior
superior iliac spine to the umbilicus
(often the point of maximal tenderness)

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What is the differential diagnosis for:
Everyone?
P295

Meckel’s diverticulum, Crohn’s
disease, perforated ulcer, pancreatitis,
mesenteric lymphadenitis, constipation,
gastroenteritis, intussusception, volvulus,
tumors, UTI (e.g., cystitis), pyelonephritis,
torsed epiploicae, cholecystitis, cecal
tumor, diverticulitis (floppy sigmoid)

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What is the differential diagnosis for:
Females?
P295

Ovarian cyst, ovarian torsion, tuboovarian
abscess, mittelschmerz, pelvic inflammatory
disease (PID), ectopic pregnancy,
ruptured pregnancy

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What lab tests should be
performed?
P296

CBC: increased WBC (>10,000 per mm
in >90% of cases), most often with a
“left shift”
Urinalysis: to evaluate for pyelonephritis
or renal calculus

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Can you have an abnormal
urinalysis with appendicitis?
P296

Yes; mild hematuria and pyuria are
common in appendicitis with pelvic
inflammation, resulting in inflammation
of the ureter

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Does a positive urinalysis
rule out appendicitis?
P296

No; ureteral inflammation resulting from
the periappendiceal inflammation can
cause abnormal urinalysis

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What additional tests can be
performed if the diagnosis is
not clear?
P296

Spiral CT, U/S (may see a large,
noncompressible appendix or fecalith),
AXR

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In acute appendicitis, what
classically precedes vomiting?
P296

Pain (in gastroenteritis, the pain

classically follows vomiting)

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What radiographic studies
are often performed?
P296

CXR: to rule out RML or RLL
     pneumonia, free air
AXR: abdominal films are usually
    nonspecific, but calcified fecalith
    present in about 5% of cases

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What are the radiographic signs of appendicitis on AXR? P296

Fecalith, sentinel loops, scoliosis away from the right because of pain, mass effect (abscess), loss of psoas shadow, loss of preperitoneal fat stripe, and (very rarely) a small amount of free air if perforated

``` With acute appendicitis, in what percentage of cases will a radiopaque fecalith be on AXR? P296 ```

Only ≈5% of the time!

What are the CT findings with acute appendicitis? P296

Periappendiceal fat stranding, appendiceal diameter >6 mm, periappendiceal fluid, fecalith

What are the preoperative medications/preparation? P297

1. Rehydration with IV fluids (LR) 2. Preoperative antibiotics with anaerobic coverage (appendix is considered part of the colon)

What is a lap appy? | P297

Laparoscopic appendectomy; used in most cases in women (can see adnexa) or if patient has a need to quickly return to physical activity, or is obese

What is the treatment for nonperforated acute appendicitis? P297

Nonperforated—prompt appendectomy (prevents perforation), 24 hours of antibiotics, discharge home usually on POD #1

What is the treatment for perforated acute appendicitis? P297

``` Perforated—IV fluid resuscitation and prompt appendectomy; all pus is drained with postoperative antibiotics continued for 3 to 7 days; wound is left open in most cases of perforation after closing the fascia (heals by secondary intention or delayed primary closure) ```

How is an appendiceal abscess that is diagnosed preoperatively treated? P297

Usually by percutaneous drainage of the abscess, antibiotic administration, and elective appendectomy ≈6 weeks later (a.k.a. interval appendectomy)

``` If a normal appendix is found upon exploration, should you take out the normal appendix? P297 ```

Yes

``` How long after removal of a NONRUPTURED appendix should antibiotics continue postoperatively? P297 ```

For 24 hours

Which antibiotic is used for NONPERFORATED appendicitis? P297

Anaerobic coverage: Cefoxitin®, | Cefotetan®, Unasyn®, Cipro®, and Flagyl®

What antibiotic is used for a PERFORATED appendix? P297

Broad-spectrum antibiotics (e.g., Amp/ Cipro®/Clinda or a penicillin such as Zosyn®)

How long do you give antibiotics for perforated appendicitis? P298

Until the patient has a normal WBC count and is afebrile, ambulating, and eating a regular diet (usually 3–7 days)

What is the risk of perforation? P298

≈25% by 24 hours from onset of symptoms, ≈50% by 36 hours, and ≈75% by 48 hours

What is the most common general surgical abdominal emergency in pregnancy? P298

Appendicitis (about 1/1750; appendix may be in the RUQ because of the enlarged uterus)

What are the possible complications of appendicitis? P298

Pelvic abscess, liver abscess, free perforation, portal pylethrombophlebitis (very rare)

What percentage of the population has a retrocecal, retroperitoneal appendix? P298

≈15%

What percentage of negative appendectomies is acceptable? P298

Up to 20%; taking out some normal appendixes is better than missing a case of acute appendicitis that eventually ruptures

Who is at risk of dying from acute appendicitis? P298

Very old and very young patients

``` What bacteria are associated with “mesenteric adenitis” that can closely mimic acute appendicitis? P298 ```

Yersinia enterolytica

What is an “incidental appendectomy”? P298

Removal of normal appendix during abdominal operation for different procedure

What are complications of an appendectomy? P298

SBO, enterocutaneous fistula, wound infection, infertility with perforation in women, increased incidence of right inguinal hernia, stump abscess

What is the most common postoperative complication? P298

Wound infection

``` CLASSIC INTRAOPERATIVE QUESTIONS What is the difference between a McBurney’s incision and a Rocky-Davis incision? P299 ```

``` McBurney’s is angled down (follows ext oblique fibers), and Rocky-Davis is straight across (transverse) ```

``` CLASSIC INTRAOPERATIVE QUESTIONS What are the layers of the abdominal wall during a McBurney incision? P299 ```

1. Skin 2. Subcutaneous fat 3. Scarpa’s fascia 4. External oblique 5. Internal oblique 6. Transversus muscle 7. Transversalis fascia 8. Preperitoneal fat 9. Peritoneum

``` CLASSIC INTRAOPERATIVE QUESTIONS What are the steps in laparoscopic appendectomy (lap appy)? P299 ```

1. Identify the appendix 2. Staple the mesoappendix (or coagulate) 3. Staple and transect the appendix at the base (or use Endoloop® and cut between) 4. Remove the appendix from the abdomen 5. Irrigate and aspirate until clear

``` CLASSIC INTRAOPERATIVE QUESTIONS Do you routinely get peritoneal cultures for acute appendicitis (nonperforated)? P299 ```

``` CLASSIC INTRAOPERATIVE QUESTIONS How can you find the appendix after identifying the cecum? P299 ```

Follow the taeniae down to where they | converge on the appendix

``` CLASSIC INTRAOPERATIVE QUESTIONS Which way should your finger sweep trying to find the appendix? P299 ```

Lateral to medial along the lateral peritoneum—this way you will not tear the mesoappendix that lies medially!

``` CLASSIC INTRAOPERATIVE QUESTIONS How do you get to a retrocecal and retroperitoneal appendix? P299 ```

Divide the lateral peritoneal attachments | of the cecum

``` CLASSIC INTRAOPERATIVE QUESTIONS Why use electrocautery on the exposed mucosa on the appendiceal stump? P299 ```

To kill the mucosal cells so they do not | form a mucocele

``` CLASSIC INTRAOPERATIVE QUESTIONS If you find Crohn’s disease in the terminal ileum, will you remove the appendix? P300 ```

Yes, if the cecal/appendiceal base is not | involved

``` CLASSIC INTRAOPERATIVE QUESTIONS If the appendix is normal what do you inspect intraoperatively? P300 ```

``` Terminal ileum: Meckel’s diverticulum, Crohn’s disease, intussusception Gynecologic: Cysts, torsion, etc. Groin: hernia, rectus sheath hematoma, adenopathy (adenitis) ```

``` CLASSIC INTRAOPERATIVE QUESTIONS Who first described the classic history and treatment for acute appendicitis? P300 ```

Reginald Fitz

CLASSIC INTRAOPERATIVE QUESTIONS Who performed the first appendectomy? P300

Harry Hancock in 1848 (McBurney | popularized the procedure in 1880s)

CLASSIC INTRAOPERATIVE QUESTIONS Who performed the first lap appy? P300

Dr. Semm (GYN) in 1983

APPENDICEAL TUMORS What is the most common appendiceal tumor? P300

Carcinoid tumor

``` APPENDICEAL TUMORS What is the treatment of appendiceal carcinoid less than 1.5 cm? P300 ```

Appendectomy (if not through the bowel | wall)

``` APPENDICEAL TUMORS What is the treatment of appendiceal carcinoid larger than 1.5 cm? P300 ```

Right hemicolectomy

``` APPENDICEAL TUMORS What percentage of appendiceal carcinoids are malignant? P300 ```

< 5%

``` APPENDICEAL TUMORS What is the differential diagnosis of appendiceal tumor? P300 ```

Carcinoid, adenocarcinoma, malignant | mucoid adenocarcinoma

``` APPENDICEAL TUMORS What type of appendiceal tumor can cause the dreaded pseudomyxoma peritonei if the appendix ruptures? P300 ```

Malignant mucoid adenocarcinoma

APPENDICEAL TUMORS What is “mittelschmerz”? P301

Pelvic pain caused by ovulation

``` APPENDICEAL TUMORS Should one remove the normal appendix with Crohn’s disease found intraoperatively? P301 ```

Yes, unless the base of the appendix is involved with Crohn’s disease, the normal appendix should be removed to avoid diagnostic confusion with appendicitis in the future